Medical Contested Case Hearing Decision Manual

Introduction

This manual is being created and updated by the Division's Hearings section. It serves as a guide for use by the Hearing Officers in deciding medical fee and necessity disputes. The primary purpose of the guide is to help Hearing Officers achieve consistency in their decisions and inform system participants of the legal principles the Hearings Section may follow in deciding medical disputes. Use of this manual is not intended to be a substitute for obtaining legal counsel or advice. The manual is an abbreviated summary of selected Medical Contested Case Hearing (MCCH) decisions. An accurate understanding of the law covered in the manual may require reading the Act, rules, cases referenced and the user's related independent research. The content of the manual does not constitute official Division policy. Application of the law to a given case will be dependent on the evidence offered at the MCCH by the parties and the facts found by the Hearing Officer based upon that evidence.

This manual will be added to and expanded as legally significant MCCH decisions are rendered and as the prevailing law changes. Users of this manual should check it periodically for additions and changes.

Organization for the Manual

The organization for the manual is based on the type of dispute. There are essentially two types of medical disputes, medical fee disputes and medical necessity disputes. Contained within each of these dispute types are sub-topics.

How to Use the Manual On the Internet

There are links from the table of contents to the section or subsection you wish to read. In addition, there are links to each reference to a statute, rule, MCCH decision, and Appeals Panel decision. Any reference to a Section (§) in the 400s refers to the 1989 Act. Any reference to a § in the 100s refers to the Division's Rules. Because many issues overlap, cross-references are added where appropriate. Also, there is a search engine for the contents of the manual.

Table of Contents

Medical Fee Disputes

• Overview
• Jurisdiction
  • Timeliness of Appeal to a DWC MCCH on Medical Fee Not Exceeding $2,000.00
• Evidence at a MCCH on a Fee Dispute
• Application of Medicare Guidelines
• Reimbursement Request by Health Care Provider (HCP)
  • 95-Day Requirement for HCP to File the Claim From Date of Service
    • Complete Bill Required
    • Carrier Request for Additional Documentation
  • Carrier Request for Additional Documentation
  • Request for Reconsideration (Rule 133.250)
• Reimbursement for Health Care Expenses Incurred by Injured Employee (IE) (Rule 133.270)
  • Responsibility of IE's Treating Doctor (TD) (Rule 180.22(c)(1))
• Request for Medical Dispute Resolution (MDR) (Rule 133.307(c)(1))
  • Request for MDR by HCP (Rule 133.307(c)(2))
  • Request for MDR by IE (Rule 133.307(c)(3))
  • Timeliness of Response to Request for MDR (Rule 133.307(d)(1))
  • Carrier Response to Request for MDR (Rule 133.307(d)(2))
• Pharmaceuticals
  • Reimbursement of Pharmaceuticals Sought by HCP
  • Reimbursement for Pharmaceutical Expenses Incurred by IE (Rule 134.504(b))
• Carrier Liability for Reimbursement of Designated Doctor (DD) Examination
• Subclaimant Status under Texas Labor Code §§409.009 and 409.0091

Medical Necessity Disputes

• Overview
• Burden of Proof
• Evidence at MCCH on Health Care Reasonably Required (22-a)
• Evidence-Based Medicine
• Expert Evidence and Testimony
• Admissibility of Expert Evidence
  • Expert Witness Must Be Qualified
  • Expert Witness Testimony Must Be Relevant
  • Expert Witness Testimony Must Be Reliable
• Weighing Expert Evidence
• Official Disability Guidelines
• Legal Presumptions
• Preauthorization of Health Care under Rule 134.600
• Appeal to a DWC MCCH on Health Care Reasonably Required (22-a)
  • Jurisdiction
    • Timeliness of Request for Appeal to a MCCH
    • Timeliness of Request for Appeal and Subject Matter Jurisdiction

Acronym List